Current and future public health is characterized by the increase of chronic and degenerative diseases, corresponding to the worldwide ageing of the population. The increasing prevalence of these conditions together with the long incubation period of the chronic diseases and the continual technological innovations, offer new opportunities to develop strategies for early diagnosis.
Public Health has an important mandate to critically assess the promises and the pitfalls of disease screening strategies. This MOOC will help you understand important concepts for screening programs that will be explored through a series of examples that are the most relevant to public health today. We will conclude with expert interviews that explore future topics that will be important for screening.
By the end of this MOOC, students should have the competency needed to be involved in the scientific field of screening, and understand the public health perspective in screening programs.
This MOOC has been designed by the University of Geneva and the University of Lausanne.
This MOOC has been prepared under the auspices of the Ecole romande de santé publique (www.ersp.ch) by Prof. Fred Paccaud, MD, MSc, Head of the Institute of Social and Preventive Medicine in Lausanne (www.iumsp.ch), in collaboration with Professor Antoine Flahault, MD, PhD, head of the Institute of Global Health, Geneva (https://www.unige.ch/medecine/isg/en/) and Prof. Gillian Bartlett-Esquilant (McGill University, Quebec/ Institute of Social and Preventive Medicine, Lausanne).

From the lesson

Evaluation, Planning, Implementation and the Future of Screening Programs

In this final module, important aspects of for the evaluation, planning and decision making about the implementation or stopping of screening programs will be presented. This material is given by Senior lecturer Jean-Luc Bulliard who is an epidemiologist in the Division of Chronic Diseases at the Institute for Social and Preventive Medicine in Lausanne. The conclusion of the module will be a series of interviews with experts on the future of disease screening in public health conducted by Dr. Gillian Bartlett-Esquilant, a visiting professor at the Institute for Social and Preventive Medicine at Lausanne. A quiz will close this module.

Meet the Instructors

Antoine Flahault

Professor of Public Health and Director of the Institute of Global Health (Faculty of Medicine, University of Geneva) and co-Director of Centre Virchow-Villermé (Université Paris Descartes)University of Geneva and Université Paris Descartes – Sorbonne Paris Cité

Fred Paccaud (In Partnership with UNIGE)

Professor of epidemiology and public health and Director of the Institute of social and preventive medicineLausanne University Hospital

Gillian Bartlett-Esquilant

Professor of Epidemiology and Research and Graduate Program Director and Associate Chair for the Department of Family Medicine at McGill University.University of Lausannne and McGill University

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For this presentation, which is split in tow parts,

we will assume that screening is the right thing to do.

That has been shown in your previous talks,

that the evidence has been reviewed, the balance of benefits and harms has been

deemed favorable, and policy has been enabled to allow screening to start.

So now, the question to deal with is, how to do it right?

How to implement a high quality, efficient, organized screening programs?

There are different healthcare systems with different ways of planning,

delivering, or providing screening.

So we do a knowledge, of course.

There is no universal best recipient on how to plan a screening program, but

what I will try to give you is some essential fundamental aspect,

which you could probably apply regardless of where or

what type of health systems you are dealing with.

It is recognized nowadays that high quality screening programs require time,

maybe several years,

to be fully implemented in order to provide its full potential benefits.

There are many components in planning screening programs.

There are nine of them that I will cover today, and

what is underlying each of these component is the multidisciplinary.

It is a key aspect which will enable to consolidate,

And assign different elements of your programs.

Excluding people who are not in your field of expertise will be your mistakes,

believing they could not contribute to the planning of your program.

But just before we look at how to start a program, it is worth thinking a little

while why sometimes screening starts in unplanned manner and

while other times it waits for centralized implementation.

Indeed, there are two major factors for unplanned screening.

The first is accessibility test, which are easy to use, require no special equipment,

or no trained operator are more likely to be widespread.

You can think of a blood test for

that specific antigen to detect early prostate cancers, or

a fecal occult blood test of qualitative nature, which is like a pregnancy test.

It give you, according to the color,

whether you have blood or not in your feces.

On the opposite, x-ray, mammography,

Quantitative fecal blood test require automatic laboratory analyses,

or otoacoustic emissions testing for newborn babies,

are test less likely to be easily accessible.

The second factors for unplanned or opportunistic screening, as it is also called,

incentive.

In different healthcare systems,

test will become available if there are markets for them.

It is less so in healthcare systems, which would allow public funding and

which, generally have traditions,

allowing health technology assessments before adopting a new screening test.

So when there is some widespread screening existing,

shifting from opportunistic screening to organized planned screening,

it's about change in management of screening.

It's a different issue from planning a screening program with different

challenges

that also takes years, but this is not the topic of this talk.

Good planning of an organized program should avoid what is a limit:

development of concomitant opportunistic screening.

So the first of the nine components I will cover about

planning screening programs is the objectives.

It may sound obvious, but it is crucial to set a clear objective.

It would help you to guide the local implementations.

One example of such objective could be to be able to identify and

divide whole eligible populations,

in settings where there's no population risk, it may be a challenge.

So if you miss maybe 10% of your

population is 10% of people who cannot be offered a screening.

The importance of screening is about repetition of the test also,

so it's important that you ensure timely repetition schedules,

maybe every 24 months if screening is planned every two years.

You can also follow-up people who are most at risk,

look why they're screened positive.

The first component in planning of screening programs is to set objectives.

It may sound obvious, but it is very important to guide local

implementations and that your objective include to maximize the benefits and

minimizing the harms of screening.

And actually, the evaluation will ensure your objectives are met.

As you can see,

there are different type of objectives that a program may have to fulfill.

It can depend and vary according to different health systems and settings.

For settings where there's no population register,

it may be important to ensure you're able to invite whole eligible populations.

You may not want to miss 10 or 20% of population and

not offering screening to your whole eligible population.

The efficiency of screening has to do with repetition of the test.

What is important is also ensure timely limitations.

You can also follow-up people most at risk, these are people have been

screened positive and referred for further investigations.

You also may need to provide a regular feedback and

screening statistics to many stakeholders and people interested in your programs.

You may have to provide also feedback to the test readers of the performance.

How sensitive or specific are they in the screening and detection of passages?

Some programs are also in charge of doing the accreditations of test readers.

It may be the physicians, laboratories, screening centers, and

they have to monitor that some standards are met.

Also is important to ensure continued new education,

providing training for your staff working in programs.

Also, research, even in newly established programs,

it is important to anticipate and manage for the change.

Maybe changing technology, change in understanding of a disease,

or the participation mechanism.

Entire research will help on these in finding better ways of training your

workforce, of improving equality of the programs, or

the criteria information given to participants.

The second component is decision aides.

I mean by that to provide flow diagrams of the population pathway that

include all the outcomes of screenings, benefits, and harm.

It is useful for the planning a screening service.

It is useful for the managing of communications, to help the primary care

physicians, in sharing decisions about screening with their patients,

and for the patients themselves to decide what is best for them.

I will give separate presentations of illustrations, of a type of box,

which can be provided to help in sharing decisions about screening.

The third component is operational policies.

This is very important to ensure consistent and equitable delivery, and

may require updates in monitoring over time.

You have here some example of operational policies.

It's important to define what are, for

instance, the medical criteria to be eligible for screening.

People may have different medical conditions.

They may have, for instance, a prior cancer.

If you're screening for cancer, do you want to include them or not?

When you invite people, are you planning to remind people in that response?

And if so, how many times?

When do you want to do it?

A few weeks, a few months after these limitations?

What do you do with people who opt-out for screening?

Should you include them, or should you reinvite them?

For some screening, the invitations is not general but

individual based on risk.

In this case, you may have to decide the criteria for more or

less frequent screening.

Policy upon screening is that you sign an informed consent

on the advantage and disadvantage of screening.

So what should you include in this consent form?

Should you include the data could be linked with our database for

the purpose and for the criteria of the purpose?

What to do, what action to take if the test results are equivocal?

And what about test results with insufficient activity

So there's enough screening activity?

or your performance do not meet the standards?

It's all the kind of questions that helps you to sort out.

The first component is to have a dedicated software,

a good information system to invite, record the results, re-invite people,

do the follow-up, and enable some monitoring or evaluation of your program.

These are the basic requirement of a software.

But you want to see some which is more flexible or

allow you to enter people at a not registered database to edit some data,

to record some specific ideal situations, people want to delay their invitations.

Well, for which you follow-up is in company,

you can find these annual cases in your database.

You want to record not only a screening result, But second test examinations.

So it was all a very important aspects you need to consider for

your screening organizations.

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